Comparative study of the influence of adductor canal block plus multimodal periarticular infiltration versus combined adductor canal block, multimodal periarticular infiltration and intra-articular epidural catheter ropivacaine infiltration on pain relief after total knee arthroplasty: a prospective study

BACKGROUND

A combined regimen of adductor canal block (ACB) and multimodal periarticular infiltration (MPI) with local anesthetic (ropivacaine) is a known effective method of controlling pain in the first 6-8 h after total knee arthroplasty (TKA); however, managing breakthrough pain after their combined effect wears off can be challenging. We hypothesized that, by additionally leaving an intra-articular epidural catheter (IAEC) inside the knee with intermittent infiltration of local anesthetic in conjunction with ACB and MPI, it would help manage the breakthrough pain when their combined effect wears off.

METHODS

We did a prospective study in our institution between December 2015 and August 2016 on a total of 206 patients undergoing primary unilateral TKA. The initial consecutive 106 patients received ACB + MPI (Group 1, n = 106), and the subsequent 100 patients received ACB + MPI + IAEC (Group 2, n = 100). The primary outcome measure was pain using visual analogue scale (VAS) recorded at 6, 12, 24 and 48 h, and the secondary outcome measures were requirement for rescue analgesics and repeat adductor canal block and length of hospital stay.

RESULTS

There was no statistically significant difference in VAS scores between the two groups at 6 h but at 12, 24 and 48 h; there was a statistically significant difference between the two groups in terms of VAS scores, rescue analgesic requirements, repeat adductor canal block and shorter hospital stay favoring the ACB + MPI + IAEC group.

CONCLUSION

Intermittent knee infiltration with ropivacaine is a safe, reproducible and effective method to control pain in the first 48 h postoperative period after TKA.

Comparative analysis of influence of adductor canal block and multimodal periarticular infiltration versus adductor canal block alone on pain and knee range of movement after total knee arthroplasty: a prospective non-randomised study

PURPOSE

Pain management after total knee arthroplasty has seen many recent advances such as peripheral nerve blocks in order to improve the functional outcome and reduce morbidity after surgery. Adductor canal block (ACB) and multimodal periarticular infiltration (MPI) are two techniques that have been proven to be efficacious individually. We hypothesized that the combination of ACB with MPI would reduce pain and improve knee range of movement (ROM) compared to ACB alone.

METHODS

A prospective non-randomized study was conducted from July 2015 to December 2015 in our institution in a total of 200 consecutive patients undergoing unilateral total knee arthroplasty who were either given ACB alone (Group 1, n = 100 patients) or ACB + MPI (Group 2, n = 100 patients). All the patients were assessed for severity of pain by Visual Analogue Scale (VAS) at 8, 24, 48 h postoperatively and knee ROM after 48 h.

RESULTS

Patients in ACB + MPI group had significantly better VAS scores at 8 h postoperatively but showed no significant difference at 24 and 48 h compared to ACB group. Patients in ACB + MPI group showed significantly better knee ROM after 48 h.

CONCLUSIONS

Our study concludes that patients receiving ACB + MPI have demonstrated better VAS scores in the immediate postoperative period but have no significant difference at the time of discharge.

Results of trabecular metal augments in Paprosky IIIA and IIIB defects

Aims

The advent of trabecular metal (TM) augments has revolutionized the management of severe bone defects during acetabular reconstruction. The purpose of this study was to evaluate patients undergoing revision total hip arthroplasty (THA) with the use of TM augments for reconstruction of Paprosky IIIA and IIIB defects.

Patients and Methods

A retrospective study was conducted at four centres between August 2008 and January 2015. Patients treated with TM augments and TM shell for a Paprosky grade IIIA or IIIB defect, in the absence of pelvic discontinuity, and who underwent revision hip arthroplasty with the use of TM augments were included in the study. A total of 41 patients with minimum follow-up of two years were included and evaluated using intention-to-treat analysis.

Results

There were 36 (87.8%) patients with a Paprosky IIIA defect and five (12.2%) patients with a Paprosky IIIB defect. The mean age was 56.7 years (28 to 94). There were 21 (51.2%) women and 20 (48.8%) men. The mean follow-up was 39.4 months (12 to 96). One (2%) patient died after eight years. No failures were noted in the series. The mean survivorship was 100% at the time of latest follow-up.

Conclusion

The results of this multicentre study showed encouraging short- and mid-term results for the use of TM augments in the management of Paprosky grade IIIA and IIIB defects. Cite this article: Bone Joint J 2018;100-B:903–8.

A comparative analysis of the role of Tranexamic acid as an independent variable in reducing intraoperative blood loss in patients undergoing conventional total knee arthroplasty versus computer-assisted total knee arthroplasty

BACKGROUND

Blood loss in total knee arthroplasty (TKA) is an area of significant concern as it has an effect on patient morbidity and hospital stay. Among many different modalities to reduce blood loss, the use of Tranexamic acid has become a standard procedure nowadays. The aim of our study was to determine if Tranexamic acid alone decreases blood loss as an independent variable irrespective of other blood loss preserving measures.

METHOD

This prospective non-randomized study included patients undergoing unilateral TKA by conventional method (Group 1) and computer-assisted TKA (Group 2). All the patients in both groups received Tranexamic acid in a dose of 10 mg/kg body weight prior to inflation of tourniquet. Blood loss in both the groups was calculated using Nadler's formula, and haemoglobin (Hb) level was calculated on day one and day three after surgery.

RESULTS

The mean drop of Hb in Group 1 was 1.608 and 1.56 g/dl in Group 2 which was statistically significant (p < 0.001); however, none of the patients in either of the groups actually required any blood transfusion postoperatively. Although there was a significant drop in haemoglobin and haematocrit in both the groups, on comparison, there was no significant difference in blood loss and fall in Hb levels between the groups (p > 0.001).

CONCLUSION

Tranexamic acid decreases blood loss in patients undergoing TKA independent of all the other blood conserving procedures.

The dynamic nature of alignment and variations in normal knees

The restoration of knee alignment is an important goal during total knee arthroplasty (TKA). In the past surgeons aimed to restore neutral limb alignment during surgery. However, previous studies have demonstrated alignment to be dynamic, varying depending on the position of the limb and the degree of weight-bearing, and between patients. We used a validated computer navigation system to measure the femorotibial mechanical angle (FTMA) in 264 knees in 77 male and 55 female healthy volunteers aged 18 to 35 years (mean 26.2). We found the mean supine alignment to be a varus angle of 1.2° (standard deviation (sd) 4), with few patients having neutral alignment. FTMA differs significantly between males and females (with a mean varus of 1.7° (sd 4) and 0.4° (sd 3.9), respectively; p = 0.008). It changes significantly with posture, the knee hyperextending by a mean of 5.6°, and coronal plane alignment becoming more varus by 2.2° (sd 3.6) on standing compared with supine. Knee alignment is different in different individuals and is dynamic in nature, changing with different postures. This may have implications for the assessment of alignment in TKA, which is achieved in non-weight-bearing conditions and which may not represent the situation observed during weight-bearing.

Posterolateral corner injuries of the knee--a review

Posterolateral corner injuries of the knee are usually associated with injuries to other structures of the knee. It is not unusual to miss this injury during the initial assessment. Undiagnosed and untreated posterolateral corner knee injury leads to significant morbidity including early osteo-arthritis of the knee. Failure to recognise and reconstruct posterolateral corner injuries is one of the important reasons for the failure of cruciate ligament reconstruction surgery. In this article we have reviewed the literature regarding anatomy, biomechanics, clinical features and treatment of the posterolateral corner injuries of the knee.

An unusual presentation of eosinophilic granuloma in an adult: a case report

Eosinophilic granuloma is the most common and benign form of a rare proliferative disorder: Langerhans' cell histiocytosis. Spinal involvement is rare and only 15 adult cases have been reported. We present an unusual variant of eosinophilic granuloma in a 25-year-old woman with radiological evidence of vertebra plana. Plain radiography, magnetic resonance imaging, bone scan, and blood tests were carried out, and a specimen was taken from L4 using computed tomography-guided biopsy. Gram staining, acid fast bacillus smear, bacterial and fungal cultures were negative. Histological examination of the biopsy showed features of eosinophilic granuloma with aggregates of Langerhans histiocytes. The patient was treated with low-grade radiotherapy at 150 cGy per day for 7 days. She was asymptomatic at one-year follow-up although the radiological picture was unchanged.